Provider Demographics
NPI:1861136327
Name:DOMERESE, MARTI MARIE
Entity type:Individual
Prefix:MRS
First Name:MARTI
Middle Name:MARIE
Last Name:DOMERESE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4785 SPITLER DR
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-9498
Mailing Address - Country:US
Mailing Address - Phone:941-962-8560
Mailing Address - Fax:
Practice Address - Street 1:3710 KATALIN CT
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-2160
Practice Address - Country:US
Practice Address - Phone:989-324-2012
Practice Address - Fax:989-778-2566
Is Sole Proprietor?:No
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician